Provider Demographics
NPI:1144415126
Name:MICHAEL WAHL MD PA
Entity Type:Organization
Organization Name:MICHAEL WAHL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-869-9300
Mailing Address - Street 1:13910 LAKESHORE BLVD
Mailing Address - Street 2:STE 140
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667
Mailing Address - Country:US
Mailing Address - Phone:727-869-9300
Mailing Address - Fax:727-869-0636
Practice Address - Street 1:13910 LAKESHORE BLVD
Practice Address - Street 2:STE 140
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-869-9300
Practice Address - Fax:727-869-0636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208G00000X
FLME62494208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280177900Medicaid
DG6180OtherPGBA
FLF30238Medicare UPIN
FLAG230Medicare PIN